Initial Experience of Robot-Assisted Laparoscopic Nephroureterectomy in Japan: A Useful Technique Using a Vessel Sealing Device for Securing a Good Surgical Field and Efficient Sealing

Introduction: Although robot-assisted nephroureterectomy (RANU) has been increasingly used worldwide, the history of RANU remains short, and the optimal surgical method for performing RANU has yet to be established. Here we introduce the ideal approach for RANU using the Vessel Sealer Extend (VSE). Materials and Surgical Technique: RANU was performed by using a da Vinci Xi surgical system with fenestrated bipolar forceps (by the left arm), and monopolar scissors or needle drivers (by the right arm), and the VSE (by the third arm). First, nephrectomy and lymphadenectomy were performed at the kidney direction stage, followed by the removal of the distal ureter and suturing of the bladder at the bladder direction stage. The key point of our technique is that the console surgeon can continue to obtain the optimal surgical field by traction using the third arm, and thus cut the tissue by smoothly switching between the right hand and the third arm without the need to exchange instruments, especially in the kidney direction stage. In this study we performed RANU in nine patients and lymphadenectomy in seven patients. The median console time was 195 (range: 165-265) min, the median blood loss was 55 (range: 5-179) ml. In eight cases of RANU using the VSE, no lymphatic leakage was observed and all procedures could be performed safely. Discussion: The use of VSE provides sufficient coagulation and optimal surgical field development, thus allowing console surgeons to perform RANU more safely.